Partnerships Between Health Care Organizations and Medical Schools in a Rapidly Changing Environment: a View from the Delivery System

Vol. 36, January Supplement S121

Section IV: UME-21 and Beyond: Outcomes and Policy Implication s for Medical Education

Partnerships Between Health Care Organizations and Medical Schools in a Rapidly Changing Environment: A View From the Delivery System

Jane Phillips, MD; Marc L. Rivo, MD, MPH; Walter J. Talamonti, MD, MPH

Background and Objectives: The Undergraduate Medical Education for the 21st Century (UME-21) project encouraged the formation or enhancement of partnerships between medical schools and health care organizations distinct from the traditional teaching hospitals. The purpose was to prepare medical students in nine content areas that were components of the UME-21 project. Despite their importance today to medical schools, such partnerships with health care organizations are a challenge to develop and maintain in the midst of a rapidly changing health care environment. This article categorizes the partnerships formed and discusses the benefits and the barriers encountered in such collaborations. Methods: Information about the partnerships was abstracted from written reports from each of the UME-21 partner schools. Additional information was obtained from personal communications with external project representatives and from a post-project survey presented to all UME-21 partner schools. Results: The eight partner schools established or enhanced 32 educational partnerships with external organizations. Exter- nal partner organizations contributed to curriculum planning and implementation, course development and presentation, and provision of clinical sites and preceptors. Twenty-seven of 32 initial affiliations continued in some form beyond the contract period. Conclusions: Partnerships formed as part of the UME-21 project improved medical students’ exposure to the health care system and their knowledge and skills for effective practice in the 21st century health system. Barriers encountered included financial pressures, changes in leadership, different organizational missions and priorities, and preexisting preju- dices against new relationships. Factors associated with successful partnerships include the presence of a health care organization and an academic “champion” dedicated to the project, strong individual relationships, and a medical school commitment to involve external partners.

(Fam Med 2004;36(January suppl):S121-S125.)

A rapid increase in affiliations among health care sys- cessful collaborations were formed and continued be- tems and between health care systems and academic yond the grant period. medical centers has been one response to an increase This paper examines the factors involved in the for- in economic pressures.1 The Undergraduate Medical mation and continuance of these affiliations and explores Education for the 21st Century (UME-21) project re- the predictors for success, the challenges, and the ben- sulted in formation of multiple affiliations between efits experienced. Effects of the affiliations on both the medical schools and health care organizations, most institutions and individuals involved are described. built on preexisting relationships modified or developed in response to the project. During the 3-year UME- Methods 21 project, many participating organizations experi- Information about the external partners was obtained enced major changes, including mergers, corporate re- from written reports provided by the eight UME-21 structuring, and changes in key personnel. Some enti- partner schools to the project’s national Executive Com- ties disappeared entirely. In spite of this, many suc- mittee and by interviews with local project directors and external partner representatives. A qualitative post- project survey administered to project directors of these schools at the final UME-21 annual meeting in March From the Office of Community-based Education, University of California, San Francisco (Dr Phillips); AvMed Health Plans, Miami (Dr Rivo); and 2002 provided further information about the 32 exter- Clinical Operations, Ford Motor Company (Dr Talamonti). nal partner organizations. S122 January 2004 Supplement Family Medicine

Results All were health plans or managed care organizations, The external partners are categorized within four three of which began with the UME-21 project and de- major groupings: 16 health plans (managed care orga- scribed UME-21 as a major reason for the partnership. nizations), eight integrated groups/health systems, four The dynamic and adaptive nature of these UME-21 community health centers and health departments, and partnerships is illustrated in the following case studies. four area health education centers (Table 1). There was one employer group (Ford Motor Company). The Partnerships Twenty-seven of 32 (84%) partnerships continued AvMed Health Plans and the University of Miami beyond UME-21. Of these, 25 (93%) began prior to the AvMed Health Plans (AvMed) was a logical choice contract, and most described UME-21 as a facilitative, to be a managed care partner with the University of but not the major, reason for development of the part- Miami. First, as Florida’s oldest and largest not-for- nership. Five partnerships did not last beyond UME-21. profit HMO, licensed in 1973 with 300,000 members

Table 1

Original Partnership Affiliations

Organization Health Plan/MCO Group/Health System CHC/Health Department AHEC Dartmouth Medical School Anthem/ BlueCross/ Hitchcock Clinic New Hampshire AHEC Blue Shield of New Hampshire Matthew Thornton Health Plan CIGNA/Healthsource

University of California, Brown and Toland Kaiser Permanente Community Health San Francisco Medical Group San Francisco Network of San Francisco City and County

University of Miami AvMed Health Plans Miami-Dade County University of Miami-Dade Health Department County AHEC Jefferson Reaves Overtown Clinic Camillus Health Center for Homeless

University of Nebraska BlueCross/BlueShield/ Nebraska Health System HMO of Nebraska Exclusive Healthcare United Health Care of the Midlands Principle Health Care

University of Pennsylvania Aetna-US Healthcare Clinical Care Associates of University of Pennsylvania Health System

University of Pittsburgh UPMC Health University Services SWPenn AHEC Organization

University of Wisconsin Unity Health Plans University of Wisconsin Wisconsin AHEC Blue Cross/Blue Shield Medical Foundation of Wisconsin Physicians Plus/ Community Physicians Network

Wayne State University Blue Care Network Henry Ford Health System The Wellness Plan Ford Motor Company Department of Healthcare Management*

• Employer group MCO—managed care organization CHC—community health center AHEC—area health education center Section IV: UME-21 and Beyond: Outcomes and Policy Implications for Medical Education Vol. 36, January Supplement S123 statewide, AvMed had a long tradition of providing care 21 project. Today, UF and University of Miami faculty to Florida’s communities and institutions. Second, contribute to AvMed as members of AvMed’s Quality AvMed and the University of Miami had recently em- Improvement and Technology Assessment Committees. barked on a special business relationship. Just prior to In addition, a University of Miami clinical faculty mem- the UME-21 request for proposals, the University of ber serves as the part-time quality medical director for Miami selected AvMed as its exclusive health plan for the University of Miami plan office. the university’s 17,000 faculty, employees, and depen- dents. Finally, the AvMed and University of Miami lead- The University of California, San Francisco (UCSF); ership were both personally committed to the partner- Brown and Toland, Kaiser Permanente; ship. AvMed’s regional medical director, who became and Community Health Network a UME-21 project co-director, was a former Division UCSF partnered with three very different health care of Medicine and Dentistry director in the Health Re- systems: (1) Brown and Toland Medical Group sources and Services Administration, while AvMed’s (BTMG), an independent physician association (IPA) group vice president for network operations was a of more than 1,200 physicians comprised of commu- former University of Miami graduate and faculty mem- nity private practice and UCSF faculty practice physi- ber in the University’s pediatric department. Just as cians, (2) San Francisco Kaiser Permanente (KP), a important, the University of Miami’s senior dean for foundation model providing care for about 160,000 of medical education, who was the UME-21 project di- San Francisco’s population, and (3) the Community rector, as well as the dean, were strongly supportive of Health Network (CHN), an extensive public health- the partnership. funded network providing care for about 55,000 of the These aforementioned factors contributed to a close uninsured and special need families of the community. partnership. AvMed’s regional medical director served For more than 40 years, physicians in all three set- as co-project director and the group vice president as a tings have participated in UCSF teaching programs. member of the UME-21 steering committee. These Many community-based private physicians who are AvMed Health Plans physicians and other staff con- members of BTMG participate as volunteer clinical tributed significantly to the UME-21 program’s devel- faculty for UCSF teaching programs. The KP health opment, gave presentations to the medical students, and system provides clinical experience for UCSF medical organized the third-year medical students’ site visit to students and residents. The CHN includes UCSF medi- AvMed Health Plans. cal students and residents in their programs and con- Midway through the 4-year contract, however, sev- tributes many hours to teaching. eral key developments threatened the entire partner- Top leadership from BTMG, KP, and CHN endorsed ship. First, the University of Miami ended its business the program, and participants included supportive mid- relationship with AvMed, selecting another managed level administrative physician-educators from all three care organization as its exclusive health plan. Second, groups. Physicians and other key leaders within each key top AvMed leadership supportive of the relation- organization had strong ongoing relationships with ship retired or left AvMed, including its chief execu- UCSF program faculty. Even so, a confluence of tive officer, group vice president for network opera- changes in the health care environment at the inception tions, and chief medical officer (CMO). Third, both of UME-21 created significant pressures at all three AvMed and the University of Miami were increasingly sites, challenging the development of a planned 6-month preoccupied with the financial constraints and pressures longitudinal clinical experience for third-year students. of a rapidly changing local health care environment. BTMG had a severe financial crisis leading to a major However, for several important reasons, the AvMed- restructuring. The resulting uncertainty, with concern Miami partnership survived and even flourished despite about decreasing income and resources, contributed to these challenges. First, the AvMed regional director and a significant decrease in availability of physician pre- the University of Miami senior dean for medical edu- ceptors and preceptorship sites. At the same time, San cation worked effectively together to maintain the part- Francisco KP deferred hospital expansion plans, elect- nership. Second, the incoming CEO and CMO both ing instead to remodel an existing facility. This pro- reaffirmed AvMed’s leadership in the UME-21 project. cess led to a temporary shortage of examination rooms, The CMO became an active faculty member in the third- significantly limiting available space for students. year medical students’ site visit and even expanded Within the CHN, financial and resource shortages led AvMed’s role in medical education by establishing a to increased pressures on an already-stressed public similar third-year student site visit at its Gainesville health sector, significantly affecting available physi- corporate office in response to interest expressed by cian resources for teaching. the University of Florida (UF). As a result, the UME-21 at UCSF planning commit- AvMed’s commitment to both the University of Mi- tee was faced with recruiting preceptors for the planned ami and UF has continued beyond the end of the UME- third-year longitudinal clinic at a time of unprecedented S124 January 2004 Supplement Family Medicine difficulty in identifying preceptors for the already- neutral. In contrast, effective medical schools had highly required 300 yearly placements in other courses. supportive top leadership with a commitment to de- Weekly planning meetings included UME-21 leader- velop effective partnerships and to integrate program ship and external partner representatives as well as pro- goals and content into the curriculum. The medical gram and clerkship directors from all affected sites. schools had an explicit process for maintaining exter- Through a combination of support from the top down, nal partner involvement during program planning and strong individual commitment from all involved in plan- implementation. Medical centers described their exter- ning, close and ongoing communication, meticulous at- nal partner organizations as very important to the tention to the concerns of each site, and individual will- schools’ educational goals, while external partners saw ingness to compromise for program needs, program the relationship as beneficial but not necessarily cen- goals were met. Supported by the response of UCSF tral to their goals. clinical faculty, a greatly expanded, 6-month longitudinal systems-based clerkship was implemented suc- Barriers Encountered cessfully. All three partners continue in ongoing rela- Academic centers and their external partners had tionships with the program, and the longitudinal clinic different economic and financial priorities. Their dif- continues as part of the core clinical curriculum. ferences were exacerbated by increasing financial pressures and limited resources in the late 1990s. Increased Wayne State University (Wayne State) expectations for physician productivity resulted in fewer and Ford Motor Company available preceptors and sites and affected available This partnership was unique. It was a partnership faculty time to fully develop and sustain external part- between an academic medical center and a large em- nerships. Developing and maintaining relationships was ployer health group providing care to 621,000 employ- a major challenge because of the sudden changes in ees, retirees, and their families. Ford Motor Company organizational structure of external partners. As de- and Wayne State had a strong preexisting relationship scribed by one health plan executive, “The important through mutual participation in the Wayne State Occu- relationships were primarily individual, yet the indi- pational Medicine Residency Program. This relation- viduals changed very rapidly.” ship involved several residency teaching sites and a Acceptance of program content by medical students, position for Ford Motor personnel on the Wayne State project faculty, and preceptors was affected by reac- Occupational Medicine Residency Advisory Committee. tions to managed care terminology, used when the For UME-21, the Ford Motor representative was di- UME-21 project began to describe the health care en- rectly involved in teaching medical students and was a vironment and nine content areas required for effec- member of the Wayne State UME-21 Steering Com- tive practice. During the project period, both the per- mittee. As a member of the steering committee, he par- ception and reality of managed care were changing rap- ticipated in curriculum development and implementa- idly, with pervasive effects on the institutions and indi- tion. viduals involved.2 Dissatisfaction with managed care Health care economics and the role of the employer was increasing, and reforms were being discussed.3 The as the purchaser of health care services through the of- term “managed care” became both limiting and poten- fering of health plans to employees, retirees, and their tially polarizing as it became increasingly synonymous families were stressed through sharing with the com- with one specific insurance model whose dominance mittee information based on aggregate data collected was being questioned. Some faculty, preceptors, and from the health plans. Communicating these economic students perceived incorrectly that the purpose of the and health issues related to caring for the Ford Motor UME-21 contract was to “sell” managed care economic Company “family” is especially important because agendas to a reluctant physician community, undermin- many of the current medical students remain within the ing acceptance of the content areas. Program responses area and become the physicians caring for Ford Motor included integrating the content areas into existing Company employees, retirees, and their families. medical school curriculum and decreasing the empha- sis on managed care. Characteristics Associated With Integrating new content and clinical experiences into Successful Affiliations a large number of diverse clinical settings was also a Successful affiliations lasting beyond the grant pe- challenge. Students, residents, and preceptors did not riod had both individual and institutional support. They necessarily “buy in” to the importance of the content had an academic “champion” and a health care organi- areas, especially if a “managed care” label was per- zation champion, with a focus from both partners on ceived. When this content lacked validation by resi- developing and sustaining relationships beyond those dents and preceptors it was less well accepted by stu- between specific individuals. The top leadership of dents. external partner organizations was either supportive or Section IV: UME-21 and Beyond: Outcomes and Policy Implications for Medical Education Vol. 36, January Supplement S125

Effect of the Affiliations on the Institutions Our conclusions are that several factors are impor- and Individuals tant in forming and sustaining successful partnerships. External partners brought to the medical centers ex- First, there needs to be a champion in both the external posure to a wide variety of new clinical resources such health care organization and the academic center. Sec- as community health centers, skilled nursing facilities ond, there must be a focus from both medical schools and rehabilitation centers, hospice programs, and health and their external partners on developing and sustain- plan administrative offices. They also provided exper- ing individual relationships, the institutional commit- tise in content areas, enhancing clinical content with ment to continuing the association beyond specific in- examples from the delivery system and participating dividuals. Third, supportive leaders are needed at the in learning modules, didactic sessions, and seminars. academic medical center and leaders in the health care The effects of the affiliations on the external partner organization must be supportive or at least neutral. Fi- organizations were less clear. Some were essentially nally, partnerships are strengthened by an external part- unaware of the overall UME-21 program except for ner important to the educational goals of the medical their own involvement, while others described benefits, center and by mutually beneficial relationships between including improved relationships with the academic individuals and institutions. While medical schools and community and the stimulation of contact with students external partners are different in their needs for suc- and faculty. Effects on individuals within the external cessful collaboration, highly effective educational part- partner organizations included expanded professional nerships can be formed. Once established, the relation- opportunities, increased recognition, mutually benefi- ship must be nurtured through a process of ongoing cial professional relationships, and satisfaction related communication and developing institutional relation- to teaching. ships that reach beyond the individual.

Discussion Acknowledgments: We thank Maxine Papadakis, MD, and Neil Schlackman, The project evaluation was not designed to obtain MD, for their thoughtful review and contributions to the manuscript. ongoing information about the external partnerships. Corresponding Author: Address correspondence to Dr Phillips, University The complexity and variety of changes experienced by of California, San Francisco, Office of Community-based Education, 500 the institutions during the grant period precluded quan- Parnassus Avenue, Box 0900, MU-3E, San Francisco, CA 94143-0900. 415- titative analysis of data. In addition, the level of detail 502-1328. Fax: 415-502-7952. [email protected]. reporting on evolution of partnership relationships was REFERENCES uneven across sites. Despite these limitations, detailed qualitative information was provided about the personal 1. Iglehart JK. Health policy report. Rapid changes for academic medical centers. Second of two parts. N Engl J Med 1995;332:407-11. and institutional relationships. 2. Simon SR, Pan RJD, Sullivan AM, et al. Views of managed care. A The factors important to partnerships formed by the survey of students, residents, faculty, and deans at medical schools in UME-21 schools share many characteristics with those the United States. N Engl J Med 1999;340:928-36. 3. Dudley RA, Luft HS. Managed care in transition. Health policy 2001. important to other educational partnerships developed, N Engl J Med 2001;344:1087-90. 4 as described by Case Western Reserve University. 4. Stevens DP, Leach DC, Warden GL, Cherniack NS. A strategy for cop- However, the UME-21 experience was unique because ing with change: an affiliation between a medical school and a man- of the large numbers and wide variety of partnerships aged care health system. Acad Med 1996;71:133-7. formed simultaneously for similar purposes. This al- lowed a qualitative assessment of factors that appear to generalize across different organizational structures.